'Fat fracture'--a physical sign mimicking tendon rupture.

The imaging techniques available to aid the diagnosis of ruptures of tendo Achillis, the rotator cuff and the tendon of tibialis posterior in rheumatoid patients are well described. However, ruptures of tendon or muscle at other sites are uncommon and may be overlooked. Diagnosis is often made by localised tenderness, swelling and a lack of active movement associated with a palpable defect. Clinical examination may be inconclusive and can be aided by imaging studies. We report two cases in which ruptures of a tendon were suspected, and ultrasound imaging demonstrated the palpable defect to be a cleavage plane in the subcutaneous fat--a 'fat fracture'.

Magnetic resonance imaging of the painful wrist.

This pictorial review illustrates the use of magnetic resonance imaging in the assessment of the painful wrist. Careful technique is essential to optimize the accuracy of MR of the wrist. MR is the investigation of choice in avascular necrosis and has an increasing role in internal derangement, trauma and soft tissue lesions.

Radiology of the paraglenoid sulcus.

The paraglenoid sulcus is a variable groove in the ilium adjacent to the inferior end of the sacroiliac joint. This study investigates the hypothesis that the groove is due to resorption at the insertion of the anterior sacroiliac ligament in response to stress. The anatomical relationships of the groove are shown with plain films, arteriography and computed tomography. Relationship to parity was tested in 70 adult female subjects; a statistically significant relationship was found, with deep grooves occurring only in parous women. An association with osteitis condensans ilii was also demonstrated. Relationship to lumbosacral posture was tested in 102 adult females, and an association with increased lumbar lordosis was found. These findings are consistent with our initial hypothesis.

Magnetic resonance imaging in acute physeal injuries.

Magnetic resonance imaging (MRI) permits noninvasive evaluation of the cartilage of the growth plate and epiphysis. This paper reports three cases where MRI was used to supplement conventional radiography in the assessment of acute physeal injuries. In the first patient, MRI was used for postoperative assessment of a radial neck fracture, avoiding further surgical exploration. In the second case, MRI was compared with ultrasonography in the diagnosis of proximal humeral epiphyseal separation in a neonate. In the third case MRI and computed tomography were compared in evaluation of a Salter-Harris type 4 distal femur fracture. In all cases MRI was diagnostic. MRI is the investigation of choice in acute complex physeal injuries, and is particularly appropriate for use prior to the appearance of the secondary ossification center.

Preoperative staging of carcinoma of the bronchus: can computed tomographic scanning reliably identify stage III tumours?

BACKGROUND: The aim of preoperative computed tomographic (CT) assessment of patients with carcinoma of the bronchus is to stage the tumour accurately, and forewarn the surgeon of any possible local extrapulmonary extension of tumour in patients considered to have potentially resectable disease. The ability of CT scanning to differentiate between conventionally resectable lung cancer (TNM stages I and II), locally advanced but resectable lung cancer (TNM stage IIIa), and locally advanced but unresectable lung cancer (TNM stage IIIb) was determined in a group of patients accepted for surgery. METHODS: Computed tomographic scans of 110 patients who underwent thoracotomy for intended resection of carcinoma of the bronchus, including 52 cases with stage III and 58 cases with stage I or II disease, were reviewed and the CT features and radiological interpretations correlated with the surgical and pathological findings. RESULTS: Thirteen CT scans were judged not to have been of diagnostic quality: of the remaining 97 cases 45 had stage III lung cancer, of whom 30 had successful resections, and 52 had stage I or stage II tumours. There was no difference in the frequencies of CT observations--including contiguity of tumour and mediastinum or chest wall, apparent mediastinal or chest wall invasion, proximity of tumour to the carina, mediastinal nodal enlargement, pulmonary collapse or consolidation and pleural effusion--in patients with stage I/II disease and patients with stage III disease. Similar results were found when the same observations were compared in all patients with resected disease and those with unresectable tumour. Sensitivity and specificity of CT was 27% and 96% respectively for tumour unresectability, 50% and 89% for mediastinal invasion, 14% and 99% for chest wall invasion, and 61% and 76% for mediastinal nodal metastases. Only 19 of 45 stage III tumours were correctly identified as being stage III and resectable or unresectable. CONCLUSIONS: In patients being considered for thoracotomy for resection of lung cancer, CT scanning used as the sole method of staging is of limited value for differentiating between stage I/II and stage III tumours. Patients should not be denied the opportunity for curative surgery on the basis of equivocal CT signs.

Pulmonary scintigraphy in suspected pulmonary embolism: how often does it change clinical management?

The effect of pulmonary scintigraphy on patient management in suspected pulmonary embolism has been assessed in 158 patients. A change in management occurred in 30% following scintigraphy. The major effect was a reduction in the total number of patients who were anticoagulated. Heparin was stopped in 42 of the 74 patients to whom it had been administered prior to the scintigram.

The computed tomographic appearances of angiosarcoma of the liver.

The computed tomographic (CT) appearances are described in five vinyl chloride workers with hepatic angiosarcoma subsequently confirmed at post-mortem. The tumour was multifocal in four patients. Non-enhanced scans were available in four cases showing hypodense masses relative to background liver. Dynamic scanning during intravenous contrast injection was performed in all five patients showing peripheral or central foci of enhancement within the tumour. On delayed post-contrast scans performed in three patients the angiosarcoma became wholly or partly isodense compared to normal liver. The CT appearances of angiosarcoma of the liver are non-specific but are consistent with a vascular tumour, and the differential diagnosis is discussed. Due to the vascularity of angiosarcoma, liver biopsy may be hazardous and can be avoided when there is a history of exposure to vinyl chloride monomer and the CT findings are consistent with the diagnosis.

Case report: gastroduodenal intussusception--an unusual cause of pancreatitis.

Gastroduodenal intussusception is a rare complication of polypoidal gastric tumours, and it has not previously been described as a cause of acute pancreatitis. We report a case of an endoscopically, radiologically and histologically proven intussuscepting gastric leiomyoma presenting with biochemical evidence of acute pancreatitis. The radiological appearance is illustrated and possible mechanisms for the pancreatitis are discussed.

Ventilation agents--what agents are currently used?

A survey of radiologists and nuclear physicians in 360 hospitals in the UK was undertaken to assess the current use of pulmonary ventilation agents. Replies were received from 340 (94%) hospitals. Of these, 200 (59%) provided lung scanning. The agents used for ventilation studies were Tc-labelled aerosols (118, 59%), 81Krm (58, 29%), 133Xe (42, 21%) and 127Xe (4, 2%). Nine (4.5%) hospitals performed perfusion scintigraphy without providing ventilation imaging. Thirty-two (16%) hospitals used more than one agent for ventilation imaging.

Acute myocarditis causing fatal ventricular arrhythmia in treated polymyositis.

A patient with definite polymyositis responded clinically to prednisolone in combination with azathioprine, with improvement in muscle strength and normalization of muscle enzyme levels. After 7 weeks' treatment the patient developed chest pain and fatal ventricular arrhythmias. An autopsy showed inflammatory myocarditis, but marked improvement in the skeletal muscle histology. This case illustrates that myocarditis may be a late complication of polymyositis despite immunosuppressive therapy.